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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800782
Report Date: 06/17/2021
Date Signed: 06/21/2021 06:20:52 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2021 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20210521114758
FACILITY NAME:D HILLSIDE PLACE IIFACILITY NUMBER:
486800782
ADMINISTRATOR:COPERO, JOHNNYFACILITY TYPE:
740
ADDRESS:103 MICHAEL CT.TELEPHONE:
(707) 552-7584
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
06/17/2021
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Johnny Copero, LicenseeTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision due to failing to seek timely medical attention.
INVESTIGATION FINDINGS:
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On 6/17/2021 Licensing Program Analyst (LPA) Tobola conducted an complaint investigation to deliver findings and met with Licensee, Johnny Copero. During the investigation LPA gathered facility files and conducted interviews with staff and outside parties.

The complaint alleges neglect/lack of care and supervision from the facility due to failing to seek timely medical attention. Based on a review of R1's records and interview with Licensee, LPA found that R1 had been provided in-facility hospice care services 7 days a week with wound care 3 days a week. The hospice agency observed and assessed R1's condition daily and completed visit logs. Based on interviews with staff and outside parties as well as a review of facility records, LPA found that on 6/19/2020 the facility Licensee observed maggots in R1's wound and immediately contacted R1's hospice services, R1's Physican and emergency medical attention. However, Licensee was unable to determine if the hospice agency had observed the maggots upon prior visits.

Report continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20210521114758
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: D HILLSIDE PLACE II
FACILITY NUMBER: 486800782
VISIT DATE: 06/17/2021
NARRATIVE
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Upon LPA's observations, interviews and record review the allegation, neglect/lack of care and supervision due to failing to seek timely medical attention is UNSUBSTANTIATED. An UNSUBSTANTIATED finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Appeal Rights given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2